Doac Failure to Prevent Ischemic Stroke in Atrial Fibrillation Patient with Mitral Valve Stenosis
Journal of the American College of Cardiology
Direct oral anticoagulants (DOAC) are used as first line treatment in patients with atrial fibrillation (AFib) due to their safety compared to warfarin. However, it has not been proven if they are as effective in patients with moderate to severe mitral stenosis (MS), as this population is usually excluded from the clinical trials.
A 67 year old man with a history of DM II, hypertension, moderate MS and AFib on apixaban presented to the emergency department with sudden onset altered mental status. Physical exam findings included left lower extremity motor weakness and hyperreflexia. Lab report was significant for INR of 2.1, a troponin level of 33 ng/ml, a creatinine increase to 2 mg/dL from baseline of 1.16 mg/dl, and a hemoglobin decrease to 9 g/dL from baseline of 14.3 g/dL over a ten day period. Fecal occult blood test was positive. CT head was unremarkable. MRI brain revealed multifocal ischemic stroke. EKG demonstrated AFib.
Diagnosis was determined to be ischemic stroke, non-ST-elevation myocardial infarction (NSTEMI), ischemic colitis, and acute kidney injury (AKI) from embolic showering. He was managed with dual antiplatelet and statin therapy for acute ischemic stroke and he was started on heparin infusion for NSTEMI. Transesophageal echo showed moderate MS and no mural thrombus. Subsequently, cardiac catheterization was performed and revealed severe MS with mitral valve area of 1.10 mm and severe multivessel disease. Percutaneous coronary intervention was done with stenting of the left anterior descending artery and the right coronary artery. The ischemic colitis and AKI were managed conservatively. Apixaban was switched to Warfarin and he was discharged in a stable clinical condition.
This case demonstrated the importance of medical optimization in patients with AFib and moderate to severe MS. Despite DOAC is the recommended in patients with AFib, there is limited data on their use as primary therapy in moderate to severe MS. This case illustrated the inadequacy of DOAC in patient with severe MS. Recognition of this therapeutic failure is crucial for the initiation of alternative therapy such as warfarin to prevent multifocal thrombi showering.
Elhouderi E, Choucair M, Almusawi Z, Abdulsada S. Doac failure to prevent ischemic stroke in atrial fibrillation patient with mitral valve stenosis. J Am Coll Cardiol 2021;77(18):2986. https://doi.org/10.1016/S0735-1097(21)04341-2.